Health effects

A heavy burden

Obesity presents a big challenge for governments and an opportunity for drug companies

IN THE DAYS when most people did not have enough to eat, being plump marked you out as wealthy enough to guzzle your fill. But wealthy probably did not mean healthy even then, and today obesity is seen as a problem mainly because a wide girth is closely linked with high blood pressure, high blood-sugar levels and an excess of cholesterol and fats in the blood. Scientists group these factors together under the heading of metabolic syndrome, which raises the risk of diabetes, heart disease and other ailments. Rising obesity rates pose a challenge not just for the individuals affected but for governments that help pay for their health care.

The most common measure of obesity, BMI, represents weight in kilos divided by height in metres squared. It is not perfect. A high BMI in an Olympic weightlifter, for example, is due to dense muscle rather than fat. Researchers have found that the total amount of fat matters much less than where exactly the fat is stored. The most harmful place is around the belly, the body type politely called apple-shaped. James de Lemos of the University of Texas Southwestern Medical Centre studied 732 adults in Dallas over seven years and found that their BMI and total body fat were not independently associated with their propensity to diabetes, but visceral belly fat, packed around the internal organs, was. BMI is a crude proxy for visceral obesity.

Far from being a passive storage unit, fatty tissue secretes hormones, including molecules that promote inflammation, explains Dr James of the International Association for the Study of Obesity. Chronically inflamed organs, in turn, stop working as they should. Overloaded fat tissue also pours out fatty acids into organs where they don’t belong, particularly the liver. At its most extreme, the build-up of fat and scarring in the liver can lead to liver failure. Non-alcoholic fatty-liver disease is relatively new; the term was coined in 1986. Now, according to some estimates, it may affect up to one-third of America’s population.

The effect of obesity on insulin levels is particularly worrying. Insulin, produced by the pancreas, has many jobs, including delivering sugar to cells to provide them with energy. But inflammation and inappropriate fat storage may keep cells from responding properly to the hormone, causing so-called insulin resistance. This prompts the pancreas to pump out more and more of it. Eventually blood-sugar levels rise out of control and the patient develops diabetes. High levels of blood sugar can lead to blindness as blood vessels swell or grow on the retina; kidney disease as the body’s natural filters are overwhelmed; and loss of limbs because of damage to nerves and blood vessels.

Excess insulin causes harm in other ways, too. People who are obese and diabetic are more likely to contract certain cancers and die from them. This may be because excess insulin supplies glucose to cancer cells, helping them replicate. Epidemiological studies confirm the hidden dangers of obesity. In a series of surveys of more than 200,000 American health workers since the 1970s, those who had gained 5-11kg over the period were up to three times as likely to have diabetes, high blood pressure and heart disease as those who had kept their weight steadier.

But there is much left to learn. The specific role of sugar and of refined carbohydrates is particularly contentious. Gary Taubes and Peter Attia, of the new Nutrition Science Initiative in California, argue that not all calories are created equal. Most problems associated with obesity, they say, are caused by sugary diets and the follow-on effects of insulin, particularly its role in encouraging fat accumulation.

Whatever the precise mechanisms, there is no doubt that obesity is implicated in a surge of chronic disease. The World Health Organisation (WHO) blames excess fat for 44% of cases of diabetes, 23% of ischaemic heart disease and over 40% for some types of cancer. This is already testing rich countries’ capacity to provide and pay for care.

Developing countries face even bigger problems. About 80% of deaths from chronic disease occur in poor and middle-income countries, which are already getting the diseases of the rich before having conquered those of the poor. And in many of those countries chronic diseases threaten to overwhelm wobbly health systems, says Ann Keeling of the International Diabetes Federation. Though treatments are available, it is often difficult to get care to those who need it and find the money to pay for it. Patients in poor and middle-income countries die younger from chronic disease than their counterparts in the rich world. In sub-Saharan Africa maternal obesity is linked with higher rates of infant mortality, find Jenny Cresswell and her colleagues at the London School of Hygiene and Tropical Medicine. In countries with a high incidence of HIV/AIDS there is an additional complication: some HIV drugs speed up the development of diabetes.

China has particular problems, not because the incidence of obesity and diabetes is unusually high but because its population, and thus the absolute number of sufferers, is so large and rates are rising. Some 92m Chinese adults are thought to have diabetes, though only 40% of them are diagnosed. Wenhui Li, an endocrinologist at Peking Union Medical College Hospital, sees undiagnosed diabetics who already have the symptoms of advanced stages of the disease. Linong Ji, president of the Chinese Diabetes Society, worries about a looming wave of patients: “We don’t have a system to identify those individuals and manage education or interventions in their lifestyles.” Treatment for obesity-related conditions in China generally remains mediocre, and increasing obesity comes on top of other adverse factors, such as a rapidly ageing population and a passion for cigarettes.

China’s government has taken some steps to deal with the problem. More than 90% of the population now has health insurance, though the quality varies. The government is also trying to make treatment available in more places; at present most patients crowd into big-city hospitals. A new plan for fighting chronic disease, published in July, aims to get people to take more exercise, reduce obesity rates, improve the care of patients with diabetes and high blood pressure and get people to eat better. It sounds more like a wish list than a serious plan of action.

However unfortunate rising obesity rates may be for those afflicted, they offer a big opportunity for pharmaceutical companies and makers of medical kit. Standard & Poor’s, a ratings agency, estimates that the diabetes market, currently worth $35 billion, will reach $58 billion by 2018, a jump of 66%. The number of patients receiving dialysis to clean their blood after kidney failure may rise by more than 6% a year between 2011 and 2020, according to Bank of America Merrill Lynch. That means a lot of extra business for Fresenius Medical Care and DaVita, the world’s two biggest dialysis companies. Similarly, obesity’s effect on the heart will boost companies like Medtronic, the world’s leader in cardiac gadgets such as pacemakers, valves and stents.

An ill wind

The health industry has already poured billions into developing treatments for chronic diseases. Statins such as Lipitor, made by Pfizer, an American drug company, help lower harmful cholesterol. Diabetics may begin treatment with metformin, an older, off-patent drug that, among other things, is thought to improve the body’s response to insulin. If that is insufficient, patients may take human insulin or newer insulin analogues. Novo Nordisk, a Danish company that specialises in diabetes, continues to invest in treatments that are simpler to use and more effective.

It helps that governments are increasingly getting involved with trying to improve the treatment of such diseases. France has contracted with Healthways, an American company, to manage care for French diabetics. In England the National Health Service (NHS) has introduced a programme called “Health Checks” that aims to examine people aged 40-74 and help them ward off chronic disease or improve the treatment they are already getting. Brazil last year began offering its citizens free drugs for high blood pressure, diabetes and asthma.

In countries where the demand for care is overwhelming, companies are increasingly prepared to help meet it. Zhang Zai Xin, a patient at the Guang’anmen South Area Hospital on the outskirts of Beijing, has been a diabetic for 30 years. The hardest part, he says, is sticking to his diet. “No more mooncake,” he sighs, “I feast with my eyes alone.” He is being treated by Ma Li, an endocrinologist trained by Project Hope, a not-for-profit organisation partly funded by Eli Lilly, a drug company based in Indianapolis. Dr Ma now teaches other doctors in Project Hope’s “train-the-trainer” programme.

Off a packed hallway in another hospital in Beijing, a nurse conducts free cholesterol tests with a tool provided by Pfizer. Patients are screened while they wait for their main appointment, so they can show the doctor their results immediately. If the doctor prescribes the company’s drug, Lipitor, so much the better. Wu Xiaobing, Pfizer China’s boss, plans to continue investing in screening programmes and training for doctors.

Perhaps the most active foreign drug company in China is Novo Nordisk. It decided to make the country a priority early on, starting in 1994. Recently it said it would spend $100m on a new research centre in Beijing. Perhaps most important, it has helped train more than 220,000 doctors in China since 2003. This has paid off. Novo Nordisk now has 62% of the Chinese market for diabetes drugs. The company is expanding its training programmes deeper into the countryside. There will be plenty to do for the extra doctors: by 2030 it expects the number of diabetics in China to rise to 130m, up nearly 50% from 2011.

Such training and screening programmes are not confined to China. Eli Lilly supports Project Hope in South Africa and India. Novo Nordisk’s work includes projects elsewhere in Asia and in Africa. Firms say such arrangements benefit both them and the country concerned, making treatment easier to get for patients and increasing sales for the companies. Facing declining revenues in the West, where patents on many blockbuster drugs have expired, firms are looking to emerging markets as a source of growth. Lipitor, for example, lost its patent in November 2011 yet continues to command a premium in China because patients are unsure about the quality of its competitors’ products. But drug companies’ training programmes make some health advocates uneasy. They fear that the companies may use them to promote its drugs even if they cost more than generic alternatives.

Tension over pricing seems bound to grow, particularly for new patented medicines. Developing countries, only too aware of the growing burden of disease, are naturally keen to bring prices down. At a United Nations General Assembly on chronic conditions last year, a serious sticking point in the negotiations was a proposed form of words that might make it harder for developing countries, under various trade agreements, to reduce prices for medicines.

By and large, the main challenge for governments, particularly in poor countries, is to find the money to treat obesity-related diseases. Treatments are readily available. But for reversing the underlying cause, obesity itself, they need the help of a dubious ally: the food companies.